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Microlevel documentation: relational database for critical path development

J E Greiner

    Seminars for Nurse Managers
    |June 1, 1994
    PubMed
    Summary
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    This study proposes a process for developing integrated hospital information systems (HISs) to capture nursing minimum data sets (NMDS). This aims to reduce paperwork, improve documentation quality, and enhance patient outcomes.

    Area of Science:

    • Health Informatics
    • Nursing Informatics
    • Information Systems

    Background:

    • Hospital Information Systems (HISs) have advanced, but few offer full integration for detailed nursing documentation.
    • Current systems often lack microlevel data capture for interventions between healthcare providers and patients.

    Purpose of the Study:

    • To propose a process for developing a fully integrated HIS.
    • To build a nursing minimum data set (NMDS) within the HIS.
    • To support case management, service costing, and nursing research.

    Main Methods:

    • The article suggests a process for HIS development focused on integrating nursing intervention data.
    • Emphasis on creating a standardized nursing minimum data set (NMDS).

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    Main Results:

    • The proposed integrated HIS aims to decrease nursing paperwork.
    • It seeks to increase direct patient care time for nurses.
    • The system is designed to improve documentation quality and patient outcomes.

    Conclusions:

    • A fully integrated HIS with NMDS can streamline nursing documentation.
    • This integration supports improved efficiency, research, and patient care quality.
    • The development of such systems is crucial for advancing nursing informatics.